Clinical screening tools · internal use only

Perinatal Screeners

Score, interpret and generate a chart-ready note. A screen tells you where to look — it never tells you what you found.

Nothing is saved. All scoring happens in this browser. No responses are stored or transmitted, and closing or refreshing the page clears everything. Use initials or an MRN rather than a full name, and paste the generated note into the client’s record.

Edinburgh Postnatal Depression Scale

“We would like to know how you have been feeling in the past week. Please select the answer that comes closest to how you have felt in the last seven days, not just how you feel today.”

Not a full name
Credit. Cox, J.L., Holden, J.M. and Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. Reproduced with the authors, title and source quoted, as the copyright terms require. Interpretation bands as printed on the source form.
Reading the score honestly.
  • The largest individual-participant meta-analysis found ≥11 the optimal cut-point (sensitivity 81%, specificity 88%). At the traditional ≥13, the EPDS misses roughly a third of major depression. A 9 is not a negative screen.
  • Item 10 asks about self-harm, not suicidal ideation. It does not ask about intent, plan, or desire to die. Any endorsement triggers a full risk assessment in session; a zero is not a risk assessment either.
  • The EPDS asks nothing about anger — a common postpartum presentation that this instrument will not detect.
  • Items 3, 4 and 5 form the anxiety subscale (EPDS-3A), reported separately below.

Abuse Assessment Screen

Administer only when the client is alone and able to speak freely. Never send this to a shared home device, and never ask it with a partner present or within earshot.

Not a full name
Credit. Abuse Assessment Screen, developed by the Nursing Research Consortium on Violence and Abuse. McFarlane, J., Parker, B., Soeken, K. and Bullock, L. (1992). Assessing for abuse during pregnancy. JAMA, 267, 3176–3178. Copyright © 1992, American Medical Association. All rights reserved.
Using it well.
  • This is a conversation opener that makes disclosure possible, not a diagnostic. Sensitivity is high; specificity varies widely across studies.
  • ACOG recommends screening at the first prenatal visit, at least once each trimester, and at the postpartum visit.
  • A completed screener sitting on a shared household device is itself a safety event. Nothing here is saved — but be deliberate about what you leave on screen.
  • A “no” today is not a “no” forever. Ask again, privately, at the next scheduled point.

PRIME Screen–Revised-5

To be administered by the provider. “Based on your experiences within the past year, please tell me how much you agree or disagree with the following statements.” The client may be shown a copy of the response scale to assist in answering.

Not a full name
Required for the age-normed cut-off
Credit. Calkins, M.E., Ered, A., Moore, T.M., White, L.K., Taylor, J., Moxam, A.B., Ruparel, K., Wolf, D.H., Satterthwaite, T.D., Kohler, C.G., Gur, R.C. and Gur, R.E. (2023). Development and Validation of a Brief Age-Normed Screening Tool for Subthreshold Psychosis Symptoms in Youth. Presented at the American Academy of Child and Adolescent Psychiatry 70th Annual Meeting, October 25, 2023, New York. Perelman School of Medicine, University of Pennsylvania. Derived from the PRIME Screen–Revised (Kobayashi et al., 2008).
Scope, stated plainly.
  • This screens for subthreshold or emerging psychosis symptoms and was developed and normed in youth. It is a referral-triage tool toward an early-psychosis pathway.
  • It is not validated in perinatal populations, and it is not the tool for suspected postpartum psychosis — that is acute in onset and needs a same-day psychiatric evaluation, not a questionnaire.
  • Specificity falls outside help-seeking samples, so in a general caseload most positives will be false. A positive means evaluate further, nothing more.
  • For Pennsylvania referrals, HeadsUp PA (Penn) maintains a directory of early-psychosis centers.
EPDS total
—of 30
Not yet scored

Chart-ready note

Paste into D — Data

If the screen is positive

Your clinical supervisor — the first call, not the last. Uncertainty is the reason to consult, not a reason to wait.
988 — Suicide & Crisis Lifeline, call or text, 24/7.
Her county crisis line — the county where she is physically sitting. County crisis, not 988, authorizes a 302.
1-800-944-4773 — Postpartum Support International. Support and referrals; not a crisis line.
1-833-852-6262 — National Maternal Mental Health Hotline, 24/7.
911 / ED — immediate danger or inability to maintain safety.